Re-evaluating manual therapy…

There have been a couple of publications recently calling for therapists to re-evaluate the role of manual therapy in healthcare (ref, ref). These opinion pieces have generated a lot of interest and discussion, and many have asked for my views on them especially as one of my blogs has been referenced. So I gave my brief thoughts on social media, but when one of my colleagues Sigurd Mikkelsen, who I respect hugely expresses his frustration and accuses me of lacking nuance, I take notice. So I thought I would expand further on these calls to re-evaluate manual therapy within healthcare.

The first thing to mention is that I am pleased these discussions are taking place in and around manual therapy as opposed to the usual attitude of ‘how dare you question something we have always done’, and I am also encouraged to see that the authors of these papers are attempting to promote a more honest, rational, and evidence-based view of what manual therapy is, what it can do, and more importantly what it can not do. I also appreciate their calls for physios not to totally abandon manual therapy even if I do fundamentally disagree.

Now most of you reading this will know or may have read my previous blogs here, here, and here about my concerns I have with manual therapy as a treatment for those in pain both in the public and private sectors, and although this is not new news it is worth stating again just how much I ‘hate’ manual therapy.

Hate is a strong word

Now when I say I ‘hate’ manual therapy I don’t actually hate it per se or those that use it, rather I hate the industry that has arisen around it for both personal and professional reasons. I also hate the many biased, elitist, and deluded gurus and teachers who continue to mislead and misinform patients and therapist about the effects and benefits of manual therapy.

I hate the manual therapy industry for promising a lot but delivering little, for wasting time, money, and resources. I hate it for confusing and misleading therapists and patients with the beliefs that these techniques are highly skilled and take years of training and dedicated practice to perfect.

They don’t.

I hate manual therapy for the pompous air of arrogance and elitism it has, for allowing some to believe that they are superior to others because they have gone through a pseudoscientific accreditation program and have a few more letters after their name, and now think they have supernatural powers of palpation and narcissistic beliefs that they can heal people.

They don’t.

I hate manual therapy for the overcomplicated grand theatrics it uses, making therapists stand in a certain way, push in a certain way, whilst pulling their stupid little faces with their noses up in the air, eyes closed, gently nodding to themselves when they think they have found and felt some illusionary stiff, sticky, misaligned joint, or a tight, adhered, knotted piece of soft tissue.

They haven’t.

I hate manual therapy for sucking the critical thinking, the common sense, and the banter out of those who use it, turning many manual therapists into witless, humourless idiots who can’t see when someone is just questioning, critiquing or even taking the piss out of their beloved treatments.

I hate manual therapy for turning some therapists into nasty, spiteful, vindictive wankers, who will attack and try to undermine another’s personal and professional reputation if they dare question, challenge, or take the piss out of their cherished treatments.

I could go on and on… but I won’t… simply put I hate the manual therapy industry, its groups, and many of its gurus for lots of reasons, but mostly for overcomplicating the simple process of touching people.

Touch your patients!

There is no doubt or argument from me that touch is an essential part of being human and it has many physical and psychological benefits. And there is no doubt or argument from me that touching our patients during an exam is an essential and vital part of our jobs, and although I don’t use any manual therapy, I still touch ALL of my patients. I make sure I spend the time to fully examine and palpate a patient who has concerns and worries about an area that hurts, as I know this is very important and often means a great deal to them.

I can’t recall how many times I have heard a patient say “he/she didn’t even look at it” when they tell me of past experiences with healthcare professionals, and I know, patients will not truly believe me or be fully reassured when I come to say that there is nothing for them to worry about when I haven’t even examined or palpated an area that is of concern or hurts them.

Using careful, caring touch in healthcare clearly has many benefits but mostly it helps reassure patients you have taken their issue seriously, it demonstrates care and empathy, and helps develop a trusting therapeutic alliance.

So just because I don’t use manual therapy and I think we need to abandon it, this doesn’t mean I think we should stop touching our patients during our examinations. This argument is often used as a strawman against my position of abandoning manual therapy and it pisses me off immensely.

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Touching and examining patients is essential, but touching patients as a treatment is not. Many disagree and tend to throw papers or articles at me like this, or this, or this that show how touch reduces pain, and how we humans need touch of others to develop and function normally, and I don’t disagree.

Being touched is essential for all of us, but here’s the kicker, its the context of how you are being touched that is essential not just the process. Being touched by your family, friends, loved ones in situations and times of need, distress, fear, love, affection, warmth etc is essential. Being touched by a medical professional although can be reassuring and comforting often isn’t in the same context as being touched by a loved one and so will not have the same effects.

If you are using manual therapy on a patient based on these reasons then I think you are missing the point of what these papers discuss, and I’d argue that if a patient is seeking your touch as a healthcare professional for any of these reasons then you have deeper psychological and social issues with the individual that you need to address and no amount of manual therapy is going to do this.

No different than a hot pack

When you look at the science of how touch reduces pain we see a complex process of neurophysiology occur (ref), and of course, touch can and does reduce pain, I won’t argue that point. However, many people, mainly manual therapist tend to overstate and over-egg this point, after all many, many things can reduce pain, such as reassurance, distraction, even bleedin swearing (ref).

When you look at the effectiveness of manual therapy on pain you won’t find much, in fact, most of the effect sizes of manual therapy are small and comparable to placebos, shams, hot packs, or going for a walk and yes I’m well aware manual therapy is about as effective as exercise on pain (refref, ref, ref)

But unlike a hot pack, walking, or exercise, manual therapy is a darn site more expensive to administer, both in cost and time. With more and more healthcare coming under more and more pressure with public services looking to save money, and private insurers also doing the same, all clinicians are finding themselves with less time with their patients. Simply put, manual therapy steals valuable time from consultations and follow up sessions which could be spent doing more important and cost-effective things.

Many physiotherapists seem to have lost sight of what their primary role is, physios are not here to simply remove or reduce patients pain, we are here to help restore function and quality of life, and this may be, and often is, whilst patients are in pain. More physios need to focus on the planning and management of achieving long-term goals of our patients, not just the short-term intermittent highly unreliable symptom modifying treatments. To do this physios need to develop better skills in communication, education, reassurance and motivation, not rubbing, poking, and pressing.

At the risk of sounding very pompous, arrogant, and snooty here, manual therapy shouldn’t be administered by university educated, highly trained diagnosticians and clinicians such as physios who are in high demand and whose skills are needed elsewhere. Instead, manual therapy belongs in the service industries like health clubs, gyms, spas, and beauty salons being administered by our other therapy colleagues who have the time to do it for longer, in more relaxing environments, and who don’t charge extortionate fees for something that is relatively simple to administer.

What a waste!

Whenever I see or hear of a skilled, experienced clinician like a physio giving their patients back massages, joint mobilisations, or manipulations, I think what a waste of time and resources for both the patient and the physio. That physio should be assessing, examining, and educating that patient instead, they should be designing, planning and overseeing a care management program that addresses their long-term goals and needs.

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For example, you don’t see nor expect to see an orthopaedic surgeon use their time in their consultations taking their own Xrays or MRIs. Nor would you expect to see an orthopaedic consultant changing a wound dressing every week on their patients, charging their normal fees to do it. This is not because they couldn’t do it, this is because they are needed and reimbursed to do other things. To ask an orthopaedic consultant to do everything that a patient needs in an episode of care is an inappropriate and gross waste of time and resources, so why do physios think differently? Why do physios think they have to do and administer everything to a patient such as manual therapy and even exercise therapy.

If there is a strong desire by a patient for some manual therapy to help them with their long-term goals, and you can not see any harm in it, then you best have made sure that the patient is fully aware and understands that it is NOT an essential intervention. They also need to know that all manual therapy’s effects are short lasting, unreliable and not fully understood. They also must understand that it doesn’t correct joint, disc, or nerves that are out of alignment, coz that shit just doesn’t happen, and it doesn’t loosen, release, melt, lengthen, or change muscles, tendons or the god damn fascia in any way shape or form either.

If they are fully aware of all of this and they still want it (usually by now most of my patients have lost interest once it has been explained like this) then refer out to a therapist working in the service industry for them to apply it, but make sure that they are not being overcharged or over treated.

Summary

So I hope I have expanded and explained my thoughts on the role of manual therapy in physiotherapy and healthcare in general. Just to summarise once more that I do strongly advocate and promote that all health care clinicians continue to use touch and palpate their patients when examining them but with the understanding that palpation is often unreliable in its ability to diagnose, but is great at reassurance and developing therapeutic alliance.

I argue and will continue to do so, that physiotherapists and all the other skilled diagnostic healthcare professionals need to move away from manual therapy as a treatment as it wastes their time and other resources. Instead, they should be referring patients who wish to have manual therapy to our colleagues working in the service industries such as gyms, spas, and salons to administer it in environments with more time and fewer costs, but only once it has been clearly and honestly explained to patients what it does and does not do.

Swearing

Finally, I will continue to question, challenge, even argue with all those who claim that there is some great skill or secret, magical, mystical, art to any manual therapy. I will continue to highlight how it doesn’t deserve the time, attention, and more importantly the money we continue to waste on it. And I will continue to challenge the many biased, financially motivated special interest groups, and their gurus, along with all the other wassocks who continue to confuse and mislead therapists and patients with their bull shit claims, expensive courses and made up pseudoscientific accreditations.

I am and will always be #TeamHandsOff

As always, thanks for reading

Adam

28 thoughts on “Re-evaluating manual therapy…

  1. Clearly this blog will appeal to those who fall into one camp and annoy others in the other camp. And Adam no doubt is seen as a leader of the nohands camp, something he seems to enjoy. I don’t see how that is different from those ‘pompous’ advocates of manual therapy Adam criticises. As a manual therapist in private practice (leech?) I benefit from the abandonment of hands on treatment by physios in the NHS. Patients are constantly complaining that they are given unconvincing reassurance and a sheet of exercises.
    If you are going to be a manual therapist, I say do it as best you can and take pride in your work, just as anyone should take pride in their work. Of course don’t be arrogant and assume you know all the answers. But observe differences in function in people, use your hands to discover as much as you can, pay close attention to what you are doing. You might become a good effective manual therapist – like Adam’s wife apparently!
    Many of the conditions we treat are difficult. We still don’t know what causes most back pain. We need to be precise and careful in refuting one theory or advocating another theory, not blowing trumpets. Think about the dimensionality of manual therapy – the number of variables needed to describe a simple manual procedure – force, time course, angle, applicator etc. There is no way we know from clinical trials if one approach is better than another and all manual therapy is equally ineffective.

  2. I’ll take the middle ground on this one and say for me, it depends. I totally agree that if people want some soft tissue mobilization it because it feels good, fuck that. There’s Massage Envy up the street and that person can go there. However, if I am utilizing a manual therapy technique to make my therapeutic exercise more effective, then I’m all for it. Truthfully, a good manual therapy technique shouldn’t take long to perform to be beneficial (Mulligan MWM’s for example).

    It really depends on what the injury is though. Does a person with a hamstring strain need a massage? Nah! They need targeted exercises as do a lot of injuries. Could a person with a stiff neck benefit from some mobilization? Maybe, but that mobe better feed right into a relevant functional therapeutic exercise to capitalize on the new ROM that was achieved.

    At the end of the day though, it should always come back to functional exercise. We are movement specialists and a person passively laying on a table like a blob isn’t movement.

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